Making sure tissue is not the issue - Pulmonologist’s perspective | Jindal Clinic Chandigarh

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Making sure tissue is not the issue -
Pulmonologists perspective
Dr. Aditya Jindal Interventional Pulmonologist
Intensivist Jindal Clinics SCO 21, Sec 20D,
Chandigarh DM Pulmonary and Critical Care
Medicine (PGI Chandigarh), FCCP
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Why tissue is the issue!

• Histopathological diagnosis
• Ruling out alternate diagnoses
• Staging
• Molecular testing
• Rebiopsy
• Research

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How to make sure?

• Think before you do
• Selection of correct site
• Choice of most appropriate procedure
• Size and number of biopsies/ other procedures
• Pre-decide all you need from the tissue
• Availability of tissue for extended studies
• mutations

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• Procedures
• BAL (bronchoalveolar lavage)
• EBB (endobronchial biopsy)
• TBLB (trans bronchial lung biopsy)
• TBNA (Trans bronchial needle aspiration from
  lymph nodes)
• EBUS-TBNA
• Thoracoscopic pleural biopsy

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Bronchoalveolar lavage
Endobronchial biopsy
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• 5-6 biopsies taken (5-20 sq mm)
• Specimen should fill cup of forceps
• More useful
• Diffuse lung involvement
• Large masses
• Peribronchial area
• Less useful
• Small nodules
• Peripheral lesions

Trans-bronchial lung biopsy
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EBUS(Endobronchial ultrasound)
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Radial probe endobronchial ultrasound for the
diagnosis of peripheral lung cancer systematic
review and meta-analysis. Streinfort et al. Eur
Respir J 2011 37 902910
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Characteristics of CT, PET, and EBUS TBNA in the
Correct Prediction of Mediastinal Lymph Node
Staging
Comparison of Endobronchial Ultrasound, Positron
Emission Tomography, and CT for Lymph Node
Staging of Lung Cancer. Yasufuku K et al. Chest
2006 130710-718
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• Meta-analysis of almost 3000 patients
• EBUS-TBNA
• Sensitivity of 0.880.93 (95 CI, 0.790.94)
• Specificity of 1.00 (95 CI, 0.921.00)
• NPV of 91 (range, 8396) 
• Sehgal et al. Endosonography Versus
  Mediastinoscopy in Mediastinal Staging of Lung
  Cancer Systematic Review and Meta-Analysis. Ann
  Thorac Surg 2016
• Cell block
• Immunohistochemistry
• Molecular testing success of gt90
• One of the lowest insufficiency rates (4) for
  EGFR and KRAS mutational analysis 
• VanderLann et al. Endobronchial ultrasound-guided
  transbronchial needle aspiration (EBUS-TBNA) an
  overview and update for the cytopathologist.
  Cancer Cytopathol. 2014
• Billah et al. EGFR and KRAS mutations in lung
  carcinoma molecular testing by using cytology
  specimens. Cancer Cytopathol. 201

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EBUS diagnosis Number Percentage
Sarcoidosis 137 55
TB 41 16
Malignancy 19 8
Others 5 2
Normal 14 5.6
Total 249

EBUS yield  
Positive 216 87
Negative 33 13

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Malignant Pleural Effusions
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Thoracoscopy
Bhatnagar R, Maskell NA. Medical pleuroscopy.
Clinics in chest medicine. 201334(3)487-500.
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Malignant mesothelioma presenting as parietal
pleural nodules
HE, 100X showing tumour cells arranged in sheets
infiltrating the soft tissue.
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